Health information exchange must overcome several barriers before it becomes widespread, say health IT experts Julie Adler-Milstein and Ashish Jha in a new commentary published last week in the Journal of the American Medical Association. The authors state that the obstacles to the effective exchange of clinical data are substantially greater than the challenge of getting most providers to adopt electronic health records.
Adler-Milstein and Jha list five barriers to data interchange; the first three of these, they contend, could be lowered through government intervention. The roadblocks include concerns among clinicians about the privacy and security of patient information in HIEs; the growing use of the Direct secure messaging protocol, which was developed by a public-private consortium including the Office of the National Coordinator for Health IT; and the exclusion of providers other than eligible professionals and hospitals from the Meaningful Use electronic health record incentive program.
Their solution to the apprehensions about HIE security is for the government "to provide greater clarity and guidance on the consequences of unauthorized data breaches caused by others." A recent change in the HIPAA law makes business partners as liable for breaches as covered entities. But what the authors apparently are referring to is the question of whether a provider is responsible for a privacy breach if another provider discloses information he or she has obtained through an HIE. There also are many other privacy issues in HIEs, as University of California San Francisco professor Robert Miller recently told FierceHealthIT.
The JAMA paper's objection to the Direct protocol is that, by enabling secure point-to-point messaging, including document attachments, Direct discourages providers from exchanging the structured data needed for accountable care and other secondary purposes. However, Direct can be used to exchange continuity of care documents that contain structured data. And some HIEs are utilizing Direct to jump-start data exchange while many providers still lack EHRs.
Moreover, the Meaningful Use Stage 2 proposal requires providers to exchange clinical summaries during 65 percent of transitions of care, and the summaries must be electronic in 10 percent of these encounters. While a CCD that satisfies this requirement can't necessarily populate the fields of disparate EHRs, the only cost-effective solution is to build more HIEs that have interfaces to those EHRs. So this proposal, if included in the final rule, should encourage interoperability and the formation of HIEs.
I totally agree that the government should include nursing homes, home health agencies, and other providers in the Meaningful Use program. But the HITECH Act does not authorize that, so Congress would have to pass another law that authorizes additional funding--not too likely in an election year.
The fourth and fifth challenges listed by Adler-Milstein and Jha have to do with the attitudes of hospitals and physicians. Many hospitals, they note, don't want to share data with their competitors, so they're not especially interested in participating in public HIEs. They'd rather build private HIEs that bind their physicians to them. I can't argue with that, but it has become increasingly clear that accountable care organizations will need access to healthcare data across their communities to do population health management. So if a hospital wants to form or join an ACO, it will have to revise its attitude toward HIEs.
Finally, the JAMA authors point out that physicians will have to be convinced that they need HIE data and will have to start using the information in their daily work. This is potentially the biggest barrier, because physicians tend not to trust patient data that comes from outside their practices; that's one reason why they often repeat tests. Also, the sheer amount of information that's available in HIEs can easily overwhelm clinicians. "Smart analytic tools do not yet exist to sift through the mounds of data that HIE will generate in order to identify the information that is valuable to clinicians at the point of care," Adler-Milstein and Jha observe.
The authors make some good points of which policy makers should take note. But their observations about hospitals and physicians reveal that the government's power to accelerate HIE information is limited. Unless the marketplace leaves providers with no alternative to using community HIEs, resistance to information exchange will persist. - Ken